US - North Carolina - Clyde
June 30, 2024
LOCATION:
Remote - must live in or near Haywood or Jackson County, North Carolina.
Must have the ability to travel in or near Vaya's region.
GENERAL STATEMENT OF JOB
Acute Transition Care Manager, Registered Nurse (ATCM, RN) reports to the Acute Transition Care Management, Registered Nurse Manager (ATCM, RN Manager) and is responsible for providing proactive intervention and coordination of care to Vaya Health members and recipients ("members") who are receiving care in an inpatient community hospital or emergency department for physical health reasons to ensure that these individuals receive appropriate transitional care and services.
ATCM, RN works with the member and care team to identify and alleviate inappropriate levels of care or care gaps through assessment, multidisciplinary team care planning, linkage and/or coordination of services needed by the member across the MH, SU, intellectual/ developmental disability ("I/DD"), traumatic brain injury ("TBI"), physical health, pharmacy, long-term services and supports ("LTSS") and unmet health-related resource needs networks, while ensuring existing or new care team members are informed of transition plan.
This position supports and may provide clinical transition planning assistance to community hospitals and tracks individuals discharged from facility settings to ensure they follow up with aftercare services and receive needed assistance to prevent further hospitalization.
The ATCM RN promotes effective cross-organization communication and maintains collaborative relationships within the organization to achieve division objectives.
The ATCM, RN maintains skills in care management, care coordination, disease management and patient transitional care management.
This position may work with internal staff, hospital staff, members, guardians/family members, community stakeholders and others as appropriate to meet member's transitional needs.
Performs other duties as assigned.
The ATCM, RN also utilizes licensed clinical knowledge and skills to assess needs, inform transition planning development, provide clinical consultation, and offer recommendations for appropriate care.
As further described below, essential job functions of the ATCM, RN includes, but may not be limited to:
This position is required to meet NC (North Carolina) Residency requirements as defined by the NC Department of Health and Human Services ("NCDHHS" or "Department").
• In some circumstances, to best meet member, provider and stakeholder needs, this position working hours to begin before Vaya's 8:
30am hours of operation
ESSENTIAL JOB FUNCTIONS
Acute Assessment, Care & Transition Planning & Interdisciplinary Care Team:
Conduct or ensure all elements of transitional care management are implemented for members during physical health inpatient stay to include, but are not limited to the following:
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